Information
INCIDENT INFORMATION
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DATE OF REPORT COMPLETION
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PERSON COMPLETING REPORT
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LOCATION OF INCIDENT
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DATE AND TIME OF INCIDENT
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LOCATE # (IF NONE, ENTER N/A)
INCIDENT DETAILS
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DESCRIBE INCIDENT IN DETAIL
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ENTER APPLICABLE IMAGES OF INCIDENT
PROPERTY DAMAGE
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IS THE INCIDENT LOCATION FREE OF PROPERTY DAMAGE?
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ENTER IMAGES OF PROPERTY DAMAGE
MEDICAL/INJURIES
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WERE THERE ANY EMPLOYEE INJURIES?
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NAME OF EMPLOYEE INJURED
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DESCRIBE INJURY IN DETAIL
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ENTER IMAGES OF INJURY
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CHECK ALL THAT APPLY BELOW
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911 NOTIFED
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FIRST AID RENDERED
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HOSPITAL NOTIFIED
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ENTER HOSPITAL NAME
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DESCRIBE ANY MEDICAL ASSISTANCE RENDERED AT INCIDENT LOCATION
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IF INJURED EMPLOYEE REFUSES MEDICAL ATTENTION, HAVE THEM SIGN HERE
REVIEW AND SIGNATURE
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EMPLOYEE COMPLETING REPORT SIGNATURE
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SUPERVISOR SIGNATURE
